British hospitals are using nurses and other healthcare professionals to fill roles normally carried out by doctors, putting patients at risk of serious harm, a ‘shocking’ dossier warns.
The British Medical Association (BMA), the doctors’ union, has compiled more than 200 accounts from doctors raising concerns about what it calls the ‘inappropriate blurring’ of professional boundaries between doctors and staff without medical degrees.
The concerns centre on advanced practitioners – nurses, paramedics, pharmacists and other healthcare professionals who undergo additional training allowing them to carry out some duties traditionally performed by doctors, such as assessing, diagnosing and treating patients.
However more than eight in ten doctors surveyed by the BMA said the way advanced practitioners currently work poses a risk to patient safety.
It found that half of UK hospitals use advanced practitioners to cover gaps in doctors’ rotas – with hospitals saying the practice was used in response to staffing pressures.
The union says this widespread substitution is happening despite being against NHS guidelines.
The dossier contains accounts of serious safety incidents, including missed diagnoses and cases in which doctors allege patients came to harm or died after being treated by advanced practitioners.
In one case, a doctor reported taking their own child to A&E with a fever, headache and neck stiffness, fearing meningitis.
BMA dossier raises concerns about ‘advanced practitioners’ working in hospitals and GP surgeries
An advanced practitioner discharged the child without blood tests or a referral, according to the account.
The child returned to hospital within 36 hours and was diagnosed with meningitis. According to the doctor, the delay in diagnosis resulted in the child developing Lemierre’s syndrome – a rare but serious complication – and needing surgery.
In another case, a doctor reported that a patient in their 60s with a history of smoking had been seen three times by an advanced nurse practitioner over six weeks for a persistent cough, weight loss and, later, swelling of the face and arm.
Despite what the doctor described as ‘every red flag’, the patient had not been sent for a chest X-ray.
They were subsequently diagnosed in A&E with lung cancer and died within weeks.
Other submissions describe advanced practitioners being used in roles normally filled by senior doctors, including on intensive care, paediatric and emergency department rotas.
In one case, a registrar alleged that an advanced critical care practitioner was being used on a registrar rota despite having inadequate airway experience, and that a patient died.
The dossier also raises concerns about patients not always being made aware that the healthcare professional treating them is not a doctor.
Dr Tom Dolphin, chair of the British Medical Association’s governing council
One doctor reported that advanced practitioners replacing doctors in a paediatric department did not always make their role clear, meaning patients often believed they were doctors.
Another account concerned a woman in her 40s who saw a pharmacist advanced practitioner after suffering unexplained weight loss and vomiting.
The doctor who submitted the account said the woman was acutely unwell but the practitioner failed to recognise the seriousness of her condition and instead referred her to a fast-track service for suspected cancer.
Her husband subsequently contacted a GP, who advised him to take her to A&E, where she was diagnosed and treated for diabetic ketoacidosis – a potentially life-threatening complication of diabetes.
Another doctor reported accompanying an advanced practitioner on a nursing home visit and claimed they prescribed antibiotics to essentially ‘every confused elderly patient’ regardless of their history.
In response to the concerns, the BMA is calling for a specific ban on non-doctors being used on doctors’ rotas.
‘We must end the headlong, unevidenced and unsafe rush to replace doctors with advanced practitioners and other non-medical roles,’ said Tom Dolphin, BMA council chair.
‘We need to see an urgent review of advanced practitioners’ scopes of practice, with the adoption of national standards which protect patients and prevent the unsafe blurring of professional boundaries.
‘And most fundamentally, we must see an end to the “taskification of medicine” across the NHS, whereby the role of a doctor is sliced into tasks and handed out to other staff.’
The dossier will be submitted to regulators and governments across England, Wales, Scotland and Northern Ireland, with the BMA arguing that NHS leaders, regulators and governments should be held to the same high standards as doctors.
Mr Dolphin added: ‘These are shocking accounts of patients being let down by the system.
‘Patients are being put at risk of harm or even death because hospital managers are putting advanced practitioners and others into roles that should be filled by doctors.
‘We have made clear, over and over, that there are times when patients must be seen by a doctor, and this testimony lays out why in extensive, excruciating detail.
‘Patients with missed diagnoses, patients with severe conditions given nothing but mild pain relief and sent on their way, and patients facing end of life conditions being offered totally substandard care: they all deserved so much better.’
Responding to the BMA’s report, an NHS England spokesman said: ‘NHS guidance is clear – advanced practitioners should never replace the role of doctors and should only be used in line with their competence and qualifications.
‘Any concerns about delayed or missed diagnosis should be reported and reviewed through established clinical governance processes, regardless of which member of staff is involved.
‘Patient safety is non-negotiable.’
